Introduction

Mental health services in China have gone through a transformation from focusing on treatment to stressing the equal importance of prevention and treatment (Chen et al., 2019). In the face of major challenges related to an aging society, preventive work needs to be promoted in the next few decades to ensure the mental wellness of older adults. This requires that scholars pay great attention to the mental health needs of this group and intervene accordingly for prophylaxis.

Studies have revealed that main factors associated with mental health among older adults include low income level, unsatisfactory health, inharmonious relationship with family, losing their only child, being an empty nester, lack of emotional interaction, and regression of social interactions and relationships (Barrio et al., 2008; Chen, 2014). Many of these problems can be direct causes of mental illness for older adults and consequently increase their need for mental health services. A study by Bao and colleagues (2006) indicated an undersupply of mental health services compared to the needs of older adults in China. Zhao (2015) further stated that despite current research on this topic, no solid and practical service system has been established and existing infrastructure is inadequate. It is imperative to address this gap between mental health needs and services for older adults in China. The current policies and services in China primarily focus on the material needs of older adults, but studies have shown that they often need support that addresses mental health and well-being in terms of psychological, emotional, and social characteristics (Bai, 2015; Lu & Guo, 2013; Mu, 2004a). Research also has shown that adequate attention has not been given to mental health problems among older adults in China (Gao, 2014).

Given China’s fast-changing society, particularly the rapid pace of globalization and digitalization, life has been affected by various challenges. It is important to understand the mental health needs of older Chinese adults and explore the policy and institutional responses to these needs.

Research Question

This study aimed to identify expressed mental health needs among different groups in the aging population to develop mental health service programs and implement appropriate policies to meet those needs. Research questions included:

  1. 1.

    What are the mental health needs of different groups in the aging population?

  2. 2.

    What are the perceived mental health needs of older adults among different stakeholders?

  3. 3.

    Which current policies reflect the mental health needs of different groups in the aging population in China?

  4. 4.

    What relevant policy and service delivery processes in the community can fulfill those needs?

Review of the Literature

Mental Health

Mental health and well-being are defined here as a general state of being content with life and not feeling depressed or anxious about current circumstances. They occur when someone perceives respect for their individuality, emotional comfort, and a capacity for social achievements that contribute to the realization and fulfillment of self-worth (Mu, 2004b). Research has demonstrated that 85% of older adults in China have mental health problems at different levels, with 23.09% of adults aged 60 or older suffering from severe mental disorders (Wu et al., 2019). It is especially true for older adults with disabilities, older adults who have lost their only child, empty nesters, and older adults living in poverty, who often have greater mental health needs.

Classification of Mental Health Needs of Older Adults

A survey of more than 500 older adults in Nanjing, China, found that their major mental health needs included respect from society and behavioral significance, receiving due attention from family and society, receiving objective comments on their hard work and contributions to society, social role transformation, and continual pursuit of social significance behind their individual actions (Liu, 2004). Some scholars summarized the mental health needs of older adults as need for emotional communication, interpersonal interaction, culture and entertainment, knowledge and education, political participation, and self-actualization (Geng & Feng, 2009; Ming, 2000; Zhou, 2007). Need for self-respect, hope, and family love were also emphasized as mental health needs (Mu, 2004b). Among these, emotional needs, need for social interaction, and need for meaning were seen as a common focus of mental health needs among older adults.

Mental Health Services Policy in China

In the early 1980s, European welfare states began to adopt policies and programs designed to respond to population aging. They developed systems that addressed the basic housing, personal care service, and mental health needs of older people (Zhou, 2005). However, mental health needs have only recently been directly addressed in social policies in China, whereas policies and programs addressing housing and personal care needs have been in place since the 1990s. We reviewed a wide range of legislation documents concerning mental health and services, and Table 1 summarizes recent major policies relevant to the provision of mental health services to older adults. The first major policy was the Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly, issued in August 1996 (No. 8 National Congress of China, 1996). Article 11 of this law stipulates that families assume the duties of offering financial and psychological support and caregiving services to older adults. However, in the ensuing years, mental health issues affecting older adults have not yet drawn attention from families and society. Since 2004, scholars have started studying the mental health issues of older adults and developed the core concepts of mental support, which emphasizes emotional support and stress release received from relatives or close friends (Fang, 2009; Zuo & Gao, 2004); psychological sustenance, which emphasizes intergenerational support (Mu, 2004a; Shao, 2006); and mental health and well-being (Chen, 2014). Compared to the first two concepts, mental health and well-being requires greater variety in terms of scope of services, types of providers, and channels of service provision.

Table 1 Presence of Mental Health Elements in Important Rules and Social Policies
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Social policies implemented between 2005 and 2012 have addressed the material needs of beneficiaries including older adults living in the community, but they have not specifically addressed mental health and well-being concerns. These policies include the reform of Basic Old Age Insurance for Urban Employees (a compulsory pension program for employees of enterprises; in Chinese pinyin: Chengzhen Zhigong Jiben Yanglao Baoxian); a pilot of Basic Old Age Insurance for Urban Residents (a voluntary pension program for urban residents aged 16 or older who are not formally employed or in formal education; in Chinese pinyin: Chengzhen Jumin Jiben Yanglao Baoxian); and policies regarding the commercialization of long-term care services for older adults.

The Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly, amended in July 2013, is regarded as a legal effort to cope with population aging in China (No. 11 National Congress of China, 2013). It highlights the mental health concerns of older people. Article 17 was added to the 2013 version, stipulating that “family members should pay heed to the mental health and well-being needs of the elderly and should not ignore or neglect them. The supporters (mainly children) who live separately from the elderly should often visit and extend greetings to the elderly. All employers should protect supporters’ rights to visit the elderly parents according to the related regulations.” Chinese citizens have interpreted this regulation as a legal requirement for children to visit their parents often. In practice, this regulation is more of a social mandate describing an expectation than a strictly enforced law in the absence of mechanisms to ensure or promote compliance. Both the 2013 and 1996 version of the Law of the People’s Republic of China on Protection of the Rights and Interests of the Elderly seek to transfer the obligation of mental support of older adults onto the family. The 2013 version also extended this responsibility to the social services sector. Local governments have aimed to set up and improve the social service system for older adults that is currently based on families and communities, known as Article 36. Further examining this law, Article 37 elaborates that local governments at all levels and related departments should take measures to encourage and support professional service agencies and other organizations, as well as individuals, to provide necessary services including caregiving, emergency assistance, medical care, mental support, and psychological consultations to older adults. Article 38 in the 2013 version acknowledges the Chinese traditions of mutual support among neighbors, including provide mental health comfort to older adults in the community. This article also encourages professional agencies and volunteers to provide various services to vulnerable older adults, including psychological counseling if needed. In addition, “participation in social development,” which was added to the 2013 version of the law, enhances opportunities for older adults by guaranteeing their right to take part in economic, political, cultural and social life; ensuring opportunities for learning among older adults are included in the lifelong education and community education system; and outlining how colleges for older adults, as part of lifelong education in the community, should help broaden their knowledge, maintain their health, nurture their sentiment, enrich their life, and assist them with successfully blending into society (Article 67 and Article 72). Although there are no explicit instructions regarding mental health and well-being in these articles, the content is relevant to these topics among older adults in society. The definition of mental health and well-being includes not only a desire to receive care from children, but also the desire to socialize with neighbors and participate in social activities. This was addressed in Article 17, which is about mental health care from children, and Articles 38, 67, and 72, which demonstrate how policy can promote socialization with neighbors and participation in social activities.

Despite these legal provisions in the 2013 version of the law, the mental health issue has not been addressed in subsequent policies on security and services for older adults issued by the State Council, National Health and Family Planning Commission, Ministry of Civil Affairs, National Development and Reform Commission, Ministry of Finance, or Ministry of Human Resources and Social Security. For example, the Notice on Government Purchasing of Old Age Services issued in August 2014 states that the government should purchase services for older adults regarding caregiving, rehabilitative treatment, and staff training (Ministry of Finance, 2014). The notice indicates that “door-to-door services should be provided to the elderly who are qualified for government subsidies. These services include helping them with feeding, showering, cleaning, emergency assistance, medical care and nursing care” (Ministry of Finance, 2014). This notice does not practically cover mental health and well-being and only mentions “old age rehabilitative and entertainment activities” in the context of basic activities of daily living that may be separate from mental health needs. Soon thereafter, the National Development and Reform Commission (2014) issued its Notice on Speeding up the Project of Health and Old Age Services in September 2014, and the National Health and Family Planning Commission (2015) issued an Announcement of Integrating Medical Care with Old Age Services in November 2015. These two documents can be deemed guiding policies in the development of the Healthy Ageing Project in China, but there is a visible absence of relevant content on mental health. The sole provision relevant to mental health can be found in the section on “encouraging the non-government sectors to set up agencies that combine medical care with old age security services” in the Announcement of Integrating Medical Care with Old Age Services. This section supports the establishment of enterprises that focus on the needs of older adults in terms of preventive and curative health care and rehabilitative care, caregiving and mental health support, and products and relevant services for these needs among older adults.

The Central Government-Funded Local Program for Severe Mental Disorder Management and Treatment, also known as Project 686, was launched in December 2004 to integrate management and treatment in hospital and community settings. This integration marked the beginning of mental health prevention and treatment at the community level, expanding mental health prevention and treatment beyond specialized hospitals. This model combines prevention and treatment and is a sustainable and meaningful measure for any population group (Ma et al., 2011).

According to Chapter III of the Regulations of Shanghai Municipality on Mental Health (Ministry of Finance, 2014), a chapter centering on mental health promotion and mental disorder prevention, responsible parties that implement measures to prevent mental illness and disorder in different sectors include mental health professionals, community health service organizations, residents’ committees, villagers’ committees, the Ministry of Education, schools, and enterprises. The enactment of this regulation demonstrates an increased awareness of mental illness prevention in China. It focused more on wellness, which goes beyond satisfying mental health needs, instead focusing on helping older adults prevent mental health problems and protect their mental health (Ma et al., 2011).

In summary, mental health services in China have received increased attention and gone through several big reformations. Even today, the model of combining prevention and treatment and integrating hospital and community resources is still suitable and effective, yet it runs short of mental illness prevention regulations and ordinances specific to older adults. Given the rapid growth of China’s aging population, more thorough and in-depth research on older adults’ mental health needs is seriously needed.

Regarding relevant policy on mental health in the community, this research took Shanghai as an example, assessing the needs of different groups of older adults to provide inspiration and enlightenment to service and policy leaders to guide relevant regulations and policies conducive to older adults’ mental health services.

Theoretical Framework: Agentivity Theory

According to agentivity theory (Wang, 1994), proposed as part of the Marxist philosophy, agentivity refers to how an agent treats the relationship between people and the material world (nature, society, and humans), consisting of agent spirit, competence, and value (Dong, 1992). Agent spirit can be interpreted as recognizing one’s overall situation in terms of the physical, psychological, and competence-related status quo, and a person with agentivity exercises their rights to fulfill the meaning of life and value (Barrio et al., 2008; He, 2005).

We assumed different agents would come up with their own values and perceptions of older adults’ mental health needs. A theoretical framework based on agentivity theory was adopted to analyze the predicament, causes, and possible solutions of the mental health and well-being challenges in urban Chinese communities.

Methods

To fulfill the research purposes and identify the gap between mental health needs and relevant policy arrangements and services, it is important to have a holistic picture from different stakeholders. Therefore, this research employed the qualitative method, involving 80 in-depth interviews with different groups of older adults, formal and informal caregivers of older adults, leaders of residents’ committees, community doctors (including family doctors), psychiatrists, geriatricians, leaders of gerontological organizations, and staff members from the National Health Commission and Ministry of Civil Affairs. The scope of participants in the study was designed by the multidisciplinary research team to ensure the saturation of data from the interviewees. The relevant stakeholders and the diverse background of the informants were considered in the project design process. This design also reflected the guideline of agentivity theory that the study should be conducted among diverse participants who bring unique values and perceptions.

The research team contacted two community carders (one in the city center, one in a suburban district) to get a list of all older adults living in the community. Random selection was applied in each group of older adults, including those with disabilities, living alone, living with a partner, and with mental illness. Other important stakeholders—namely, psychiatrists, community doctors, community leaders, social organization service providers, and civil affair officers—were interviewed. Tables 2 and 3 show the participants’ general information. Different agent views, thus, have been included to reach an in-depth understanding of the mental health needs of older adults.

Table 2 Profile of Older adults
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Table 3 Other informants
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After informing the participants about the study and obtaining their consent, interviews were audio recorded for later transcription by two authors of this paper. Eighty records were transcribed, coded, and further interpreted. Thematic analyses were employed to interpret the data. The first round of line-by-line coding was carried out by one author, then assessed by another author; categories and dimensions were initially identified by both authors. Thematic analyses were jointly conducted by the two authors thereafter. Referring to the research questions and the data, the following procedures were carried out to fulfill the thematic analysis: (1) identify a clear topic; (2) connect major conceptual generics to subconceptual generics through a decoding paradigm model; (3) develop and verify relationship between the conceptual categories and dimensions; and (4) synthesize categories that may be further developed. The whole process followed the guidelines of the research questions and the nature of the data. After several rounds of comprehensive discussions by the research team regarding social science, psychiatric, medical anthropology, and social policy aspects of the data, the final analysis output was achieved and illustrated in these findings.

Findings

From the analysis of the interview records, we found older adults generally had needs related to social interaction, stress relief, and aging well. Different groups had unique needs, as specified in subsequent sections. Different agents had different perceptions of the mental health needs of older adults.

Mental Health Needs Perceived By Older Adults

Based on diverse agent interviews, we learned that when older adults’ basic needs were satisfied and remain stable, their needs progressed to the psychological level, related to social interaction, belonging, and self-actualization. Different aging groups had shared and unique needs; even in the same category of needs, there tended to be variations between groups.

Primary Mental Health Needs Among Older Adults

Social Interaction

Interview data indicated that most older adults loved social interactions and hoped to enrich their social life.

Comforting each other and talking to people are pretty enjoyable. It’s very helpful for me to talk with people, to help each another and to have conversations with each another. (A7, A8, A11)

The most comfortable thing for me is to be with people, going out for a trip or an activity. My favorite thing in a day is to come here [community center]. Regardless of how far I live away from here, I will come here every day. It’s such a joy to join these people and plan our next trip together. (A21)

Sense of Belonging

A sense of belonging builds on the foundation of social interaction. During social interactions, older adults could find like-minded people and make friends, build their social network, function in their network, and develop hobbies and interests. An enhanced sense of belonging was also conducive to a greater sense of self-worth and thus, beneficial for the mental health of older adults.

[The] community center takes me out of myself. I’ve made many friends and feel happier. (A13, A15, E2, G7)

Self-actualization

After retirement, if they were not rehired or joined other social activities, older adults needed to redefine their roles and regain self-worth and self-identification from their new roles. Otherwise, their quality of life might be negatively affected by the huge gap before and after retirement. During interviews, older adults expressed their desire to engage in meaningful, worthwhile, and pleasurable activities, and most of them sought to achieve this through self-improvement (acquiring new knowledge, exploring interests) and volunteering.

I spend one hour a day practicing oral English. I can sometimes even engage in simple conversations. Like when I’m on an airplane, I can greet people in English. I feel very satisfied. Learning English is now my biggest joy. (A4)

Voluntary activities themselves are a kind of contribution to the community. I feel quite happy when I volunteer. People in residents’ committee always ask us to make suggestions or participate in discussions and even appraisal of committee leaders. It’s a soul-cleansing activity for me, and I’m happy to do that. (A5)

Needs of Special Groups

Older adults living alone: Fighting against loneliness.

The biggest challenge for older adults living alone was loneliness. If nothing happened to attract their attention or relieve their loneliness, they were prone to a vicious cycle, which affected the quality of their later life. They did not like being alone and wished their loneliness could be relieved.

After my spouse was gone, I’ve always felt a little lonely. (F2)

I’ve lost pleasure in life. Since my husband passed away, it’s been so hard of being alone. (F6)

I feel lonely. I wish to have a companion. (F6)

How is it possible not to feel lonely when you are old? It’d be better if you have family around to talk with and do things together. (F7)

I wish (my daughter could visit me more often). At my age, it’s natural to have such expectation. (F3)

Older adults with physical disabilities: Reducing discrimination.

Older adults with physical disabilities regarded their disability as a shortcoming and weakness, which was typically accompanied by a lower level of confidence and tendency to feel inferior. Therefore, they sought respect from family, friends, and society.

I sometimes feel not confident enough to participate in activities. I feel inferior to others. (G10)

What do we need? Nothing else but understanding and respect. (G10)

Older adults with mental illness: Need for acceptance.

Common mental disorders among older adults included anxiety, depression, and dementia. This group of older adults faced ambivalence: They wished to have their psychological problems diagnosed and treated. But once their diagnosis was confirmed, due to the stereotype that “people with mental illnesses are freaks” (H1, H6), they had to face the challenge of not only gaining self-acceptance but also gaining acceptance from their family, friends, and society.

It became evident during interviews that older adults were reluctant to hear words like “mental health” or “psychological treatment,” and they equated counseling with a mental health disorder. When asked if they have any mental health needs or used any psychological services, they either were quite resistant to answer or would deny it, avoiding this matter and exhibiting fear of being despised or labeled.

What an illness! Well, I think it’s better for me to die. The earlier I die, the earlier I’m released. (H2)

During rehabilitation, these older adults often didn’t receive proper guidance and thus, did not have an adequate understanding of the illness or proper follow-up treatment based on their diagnosis. Professional counseling for them is very much needed.

I haven’t experienced anything [pleasant] over the past one year since I got sick. (H5)

Nothing interests me. Ever since this illness, I’ve stopped contacting people. (H5)

We don’t know even basic rehabilitation methods, neither am I willing to ask for professional service. We need proper guides, for sure. (H2, H5)

Mental Health Needs Perceived By Others

Food and Shelter As Major Needs

Our study also involved leaders in social organizations and government officers to learn about the mental health needs of older adults from different perspectives. Most responses demonstrated that these participants saw needs for daily living, physical health, and care as the foundation and priority for older adults. These participants focused more on older adults’ daily living needs, which including aging plans, material supplies, living environment, and physical health. This fact is also reflected in current policy and services.

Regarding the relationship between the mental and physical health of older adults, an administrator of a senior service center in Shanghai stated that meeting the mental and physical health needs of older adults is a gradual and sequential process, with promoting physical health as the primary need among older adults.

I think for older adults, they go step by step. They should first have their physical needs satisfied. By the time their physical health is not much of a concern, they will begin to gradually take some mental health needs into consideration. I think it’s a process. (K1)

I think mental health has not been taken seriously. The prerequisite is having food and shelter. There are five needs; physical need takes the first place, so mental health need has to go in the third, fourth, or even fifth place, right? Only when we have adequate food and shelter, our country becomes rich and powerful, and our self-esteem grows strong will we seek to satisfy our mental health need. Need for safety and value go first, right? So, I feel it’s not been easy for the government. (K4)

Similarly, from the perspective of community cadres and community center doctors, physical health is the most basic need among older adults. Many of them agreed that only when physical health needs are satisfied will people seek support for mental health needs.

People now all pay great attention to physical health. If there is a guest lecture provided, they all will actively participate. They get great benefit from that and get to know how to stay healthy physically. (K6)

For example, the topic may be on high blood pressure, as frequently talked about in our life. They often don’t offer classes that are less popular, like gout or bone fracture and so on. (K5)

I feel what older adults need is actually a need for a state of physical wellness. Take the problem of memory loss as an example: Some older adults may want to know if there is any self-examination or if they could do any active exercise at home and so on. (L1)

Health-related topics are very popular, especially when we once invited a pain management doctor. He talked about joint problems among the elderly, which was very popular. We also provide Red Cross rescue training. We usually notify 50 people, but always have 60 to 70 people showing up. If we notify 30 people, we typically have 40 to 50 coming. The classroom is always filled with people. (L3)

Mental health development is still at its initial stage. … At this point, physical health is still the most important thing. If a person is in a relatively low economic status, I don’t think mental health is priority what they need. (L4)

Echoing these comments, leaders from residents’ committee, district-level civil affairs branch offices, and relevant social organizations also viewed physical health as the highest priority need among older adults (K4, K5, K6, M2).

Community Cadres and Nongovernmental Leaders Focused On Older Adults With Special Needs

Community cadres paid more attention to the unique needs of older adults with special situations, such as empty nesters, people living alone, older adults who lost their only child (失独老人 shi du lao ren), and older adults with disabilities. To promote mental health in the diverse aging population, all groups of older adults need to be considered.

[As for the service population], I think the service has to go with the need; for example, those most needy, those who lost their only child, the lonely ones, those who live alone and age alone. (L4)

During the interview, the administrator of a senior housing program in Shanghai expressed that the essence of staying healthy physically and mentally for older adults is to strengthen them internally and help them build a positive attitude toward life. Besides the influence of hormones, the participant stated that emotional and psychological problems are also largely affected by our consciousness. This participant also argued that if older adults can handle and deal with every situation with a positive attitude, then their psychological problems can be solved without much difficulty.

We need special attention here. We’ve also realized that through such intervention, we touch the essence of the problem of the older adults—motivating them to understand they should have a positive attitude toward life. This is the most effective way. (L2)

Doctors Reported Reluctance to Use Mental Health or Counseling Services

Rarely did older Chinese adults use any counseling services in the community. On one hand, in traditional Chinese ideology, emotional and psychological problems are people’s personal business and should be handled personally; because it may reveal their personal secrets, people are not willing to share these details with a stranger. On the other hand, “mental illness” is a despised term in most people’s eyes, and people with mental illness are often treated differently. Therefore, they are reluctant to receive psychological treatment and fear being despised and excluded by society (N2, N7).

Despite emotional disturbances, most older adults chose to keep it to themselves until they progressed to a diagnosed psychological disorder (N3, K5).

We are not doing much mental health-related stuff. We reach out more often, sometimes the attorneys may come to our neighborhood and some people may come for individual counseling. But it’s rare to see any psychological counseling. (N2)

These findings echo the fact that only a small percentage of older adults with a history of psychological disorders recognized and accepted counseling services (A8, H4). Most participants were reluctant to seek counseling services. Even in relevant social organizations or agencies, professional counseling psychologists are rare. Generally, only a small number of older adults have received counseling.

Policy Recognition: Social Service Delivery Process

Policies Leaning Toward Securing Basic Needs

As the country with the largest population in the world, China has always been dedicated to addressing the basic living needs of clothing, food, shelter, and transportation for its people. During an interview with a leader from the civil affairs branch of a street office, he mentioned that national policy will gradually lead to mental health development, but addressing basic living needs will still remain a top priority for a long time and mental health issues will remain secondary.

I feel that mental health needs are still secondary because we have too many things to handle and there are too many basic things we have to secure first. Problems at the mental health level have to be put off. It’s not that we don’t do anything about it; we have the Shanghai Senior Companion Program, which is quite approachable for people with loneliness. But how to offer services in real practice still awaits a scientific approach. (M2)

As noted in the previous policy review section, mental health services are still a relatively new concept in both policy and service provision. Service provided by residents’ committee and various social organizations still focus more on joy and pleasure.

Service Provision By Residents’ Committee: Recreational Activities and Care

Leaders of residents’ committee often described promoting mental wellness as offering activities to make older adults happy and taking care of older adults. The main reason this understanding exists is that recreational activities do alleviate anxiety and stress for older adults to some extent, making them relaxed and preventing mental disorders (K3, K6). Frequent care alleviates feelings of loneliness, enhances their sense of presence, and raises self-worth. All these are deemed conducive to mental health among older adults.

We’ve been doing a good job taking care of the older adults in our neighborhood. The government may require that we visit them every three days, but here regardless of government officials or care team, we all have been very diligent in visiting, greeting, and caring for the elderly. You can interview the older adults here and ask their comment about us. Why I’m so confident? Because based on the information we’ve collected, I haven’t heard about a single complaint so far. (K4)

Mental health wise, the main thing we’ve initiated is providing and enriching cultural and recreational activities for them. (K5)

Prevention is definitely more important. We provide activities for them to join, which is beneficial for them. They also have the opportunity to exercise their brain and communicate with people around, which are similar preventive measures. (K5)

They live a happy life. Don’t be concerned too much about what to give them. They don’t request much, only that they felt they could be organized with recreational activities and be cared for by others. Our residents’ committee is doing a good job on organizing those activities. (K7)

Service Provision By Local Social Organizations: Helping Older Adults Find Joy and Pleasure

As seen in interviews with service providers from social organizations in the community, promoting physical health was the highest priority, and although they paid more attention to special groups, such as older adults living alone, their services in general were quite limited.

Many older adults were members of senior associations in their neighborhood, where they developed hobbies, discovered interests, and enriched their social interactions. During our communication with leaders of a neighborhood senior association, we learned that in addition to regular schedules for hobby and interest development, they also invite a few certified instructors to give lectures, the main topic of which involved physical health, with very few lectures on mental health.

Classes on mental health are also offered, but not as many. … More content is about nursing care for older adults. The lecturer lived in another district; he stopped coming here to give lectures later. (L1)

Compared with other older adults, those who live alone, have disabilities, or have other special needs cannot be satisfied merely by recreational activities or care. According to an instructor at a senior association, although older adults who lost their only child or have other special circumstances may have their negative emotions alleviated through different activities, the effect is rarely sustained. Given these situations, assistance from professionals, like a counselor or social worker, is necessary.

The lady is 72 years old; she is also under our care. She’s been living alone since her husband died. Besides taking care of her, we also encourage her to go out to participate in activities. (L3)

When his son was still around, he was quite active. But ever since his son passed away, though he still comes, you can feel his frustration. … How to help them? It seems no matter what effort we make, they are still the same. How can you change a person’s inner world? That’s my opinion. (L5)

Unmet Needs and Professional Service Provision

Interviews with older adults and staff members at relevant organizations revealed that whether in the community or at a residents’ committee or hospital, professional counseling resources are very rare. One reason is that professional counseling is a very demanding job, qualified professional counselors are lacking, and counseling is still at its initial stage in China. Another reason is that the recognition and credibility of professional counseling haven’t been widely accepted in China. In the community, widely accepted approaches to promoting older adults’ psychosocial health include activities offered in community centers, lifelong learning at a college for older adults, and activities and promotions arranged by senior associations. This leaves no market for counseling, leading to sluggish counseling development and thus, few professional providers.

We haven’t seen any specialized mental health organizations. We all like making crafts and doing other activities. These activities also have some impacts on mental health. (A3)

Community voluntary activities themselves are a kind of contribution. I feel quite happy when I volunteer. People in residents’ committee always ask us to make suggestions or participate in discussions and even the appraisal of committee leaders. It’s a soul-cleansing activity for me, and I’m happy to do that. (A5)

However, some community cadres and doctors recognized the shortage of mental health services.

Many older adults nowadays have huge amounts of needs; the most important is their mental health needs, which means having people around solving their problems and helping with their daily living. (K1)

We are really short-handed. There’re so many older adults. (K4)

As the saying goes, “Soft fire makes sweet malt.” The number of patients you assign to each doctor and the amount of time each doctor has for all his patients determine how long each session is for a single patient. Even if time is not a problem for the doctor, whether he is capable of taking care of that many patients remains a concern. (N4)

The many activities provided are good, but only beneficial to those who are healthy. Older adults who are physically ill and bedbound do not get benefit from these activities; they don’t have their mental health needs taken care of, either. (A4)

Other Policy and Service Responses

The needs assessment revealed that not all older adults had the same needs; similarly, during policy making, adjustments need to be made to cater to different cases and situations. Major needs among older adults also included the need for social interaction, sense of belonging, and self-actualization. Special older adults had additional needs; for instance, older adults who lived alone had the need to fight against loneliness, older adults with physical disabilities had the need for respect from society, older adults with psychological disabilities had the need for acceptance, and so on. This has implications regarding current policy and its areas of development.

Care Team for Older Adults

A care team for older adults in the community normally includes legal and psychological counseling experts. When older adults have emotional distress or a family dispute, they can come to the team for psychological or legal counseling. But according to research, not many communities have both counseling services readily available, and even if they provide these services, people tend to utilize legal counseling far more heavily than psychological counseling (K1, K2). Moreover, psychological counseling services may not be up to standard. People who serve as counselors may not even have qualifications.

Senior Companion Plan

The literature indicates that many communities in Shanghai have adopted the model of older adult companion care—namely, “senior companion” programs wherein young-old adults are paired with middle-old and old-old adults at a one-to-one ratio or more, conducting regular visits with and caring for older adults daily. This plan is mainly designed for older adults who live alone. This serves both groups in that young-old adults receive a pathway to self-actualization and self-worth and middle-old and old-old adults receive care and attention. This type of voluntary work is very demanding of care companions’ initiative and quality, requiring sufficient motivation and interest to keep up the work.

Wellness and Recreational Activities

This study found that the most popular activity conducive to older adults’ mental health was recreational activities, including health talks, holiday events, and hobby classes. All these activities are considered beneficial for older adults’ mental health, whether they are arranged by a residents’ committee, community center, social organization, or senior living facility. That said, mental health is by no means protected solely by providing activities. Services should also include professional psychological testing, problem identification, problem prevention, psychological counseling, psychological treatment, crisis intervention, and so forth. Although these services are available, they are poorly recognized and underutilized.

Mental Health Services Provided By Nonprofessionals

Whether in residents’ committees, social organizations, hospitals, or senior living facilities, staff members are commonly aware of mental health issues and often seek to promote older adults’ mental wellness by organizing activities and coordinating volunteers, care companions, and medical social workers. As conducive as these measures are to promoting older adults’ mental health, these staff members often lack psychological knowledge necessary for accurate recognition of mental disorders and cognitive disorders among older adults, thus resulting in delayed diagnosis and treatment.

Discussion and Implications

This study aimed to understand the needs of older adults via a mental health needs assessment with different groups in the aging population to bring more attention to mental health issues among older adults from both society and the government and ensure older adults actively seek more emotional interactions and support in life.

Different Agents’ Views On Mental Health Needs of Older Adults

Based on the findings of this study, we recognize that a gap exists between different stakeholders in their understanding of mental health needs and relevant services among older adults. Particularly, there are different expectations from older people and the critical people who work closely with them. This echoes the agent spirit that an individual exercises their rights to fulfill their value and meaning of life. Therefore, we identified several services and policies that are needed for a better age-friendly environment.

Unmatched Policy Responses to Mental Health Needs of Older Adults

The literature on policy response and interviews with service delivery specialists revealed unmet needs among older adults in both policy and service aspects. Echoing agentivity theory, perceptions from different agent may interfere with their own values and holistic understanding of the world. In the interviews, it is quite evident that officers and policy makers had different perceptions relative to older adult groups (K4, K5, K6, M2). Chinese society has aged very fast in the past two decades, without enough policy and social welfare preparation (Chen & Levcoff, 2017). There is no shortcut to fulfill the comprehensive responses to the changing needs of older adults needed in this rapidly developing society. Particularly, policy makers should employ constant investigations to study the unmet needs of all older adults and take action to address the different hierarchies of needs. Mental health needs apparently have been underaddressed in current stage due to limited resources and lack of scientific studies. The following strategies might address these needs in future.

Mental Health Education

Mental health services are far less recognized in China than in other countries, as is the importance of mental health among older adults. People in their later stage of life have already gone through several enormous social changes and thus, they have had to adapt to plenty of new things. Furthermore, given the deeply ingrained traditional Chinese culture, seeking counseling or psychological treatment is still rare in the aging population. Counseling and psychological treatments have been tied to “freaks” and are considered negative, which makes people reluctant to utilize these services. Therefore, it is imperative that mental health education reach every corner of society to lower the risk of mental illness as well as address the stigma surrounding treatment.

Recreational activities are a good measure to encourage older adults’ participation, improve their social interactions and communication, develop their hobbies and interests, and enrich their life in terms of mental wellness. Common forms of recreational activity include sports, singing, dancing, crafts, and holiday gatherings. Some organizations have also started creative activities for older adults—for example, “yoga for seniors” and “fashion team for older adults”—which integrate the elements of youth and fashionable colors into older adults’ lives, and they have become very popular and much favored among older adults.

Increasing Professional Services and Training

Besides informal caregivers, geriatricians, community doctors, social workers, and staff members at senior living facilities are all service providers for older adults. When managing different cases, service providers should have an in-depth understanding of each older person’s situation and consider their specific needs, providing individualized solutions. As previously noted, current services are more favorable for healthy older adults; those with disabilities or other special needs were mostly excluded. Providing professional services that meet different mental health needs should be a joint effort across multiple stakeholders.

Regarding mental health literacy, this study found that the number of service providers for older adults is relatively small. One reason is the lack of professional assistants in both quantity and quality. Another reason is that the number of psychiatrists is very small and the time allotted to each older client is limited; thus, not enough services are accessible to promote older adults’ mental health. Mental health professionals are in great demand yet have minimal growth. Therefore, more volunteers and personal assistants must be trained.